Portal de Periódicos da CAPES

Downfolding of the Epiglottis During Intubation

2010; Lippincott Williams & Wilkins; Volume: 110; Issue: 4 Linguagem: Inglês

10.1213/ane.0b013e3181ce716f

1526-7598

André van Zundert, T. van Zundert, J. Brimacombe,

Foreign Body Medical Cases

To the Editor: A common cause of airway obstruction after insertion of a laryngeal mask is downfolding of the epiglottis,1–5 which occurs in 20% to 56% of patients.6,7 Recently, Takenaka et al.8 noted that epiglottic downfolding can occur during fiberoptic intubation. We have discovered through routine use of videolaryngoscopy with video recording (C-Mac®, Karl Storz, Tuttlingen, Germany) that (1) epiglottic downfolding can also occur during laryngoscope-guided tracheal intubation; (2) it is often severe enough to displace the epiglottis into the glottic aperture and through the vocal cords but not beyond the cricoid; (3) it does not necessarily impede tracheal intubation; and (4) the epiglottis can remain within the laryngeal inlet after tracheal intubation (Fig. 1). In principle, this could be a cause of unexpected epiglottic and/or laryngeal injury. We are currently conducting a study to determine the frequency and clinical importance of this phenomenon, which is more easily missed during conventional laryngoscope-guided tracheal intubation, because the clinician spends less time observing the laryngeal inlet, and therefore, the vocal cords may not be seen. Meanwhile, clinicians should be aware of this possibility because it might be the cause of postoperative hoarseness and dysphonia. This still has to be studied. Tracheal displacement of the epiglottis is easily corrected by elevating the vallecula with a Macintosh blade.Figure 1: Different images showing downfolding of the epiglottis during intubation of the trachea, obtained with a videolaryngoscope in a healthy patient with normal airway parameters. A, Cormack-Lehane grade III; B, epiglottis tucked into the laryngeal inlet; C, full exposure of vocal cords; D, endotracheal tube in situ; E, endotracheal tube in situ during withdrawal of the laryngoscope blade, with epiglottis still downfolded; F, restored position of the epiglottis.André van Zundert, MD, PhD, FRCA Department of Anesthesiology Catharina Hospital–Brabant Medical School Eindhoven, The Netherlands [email protected] Tom van Zundert, BSc Joseph Brimacombe, MD, PhD, FRCA Department of Anesthesiology Cairns Hospital, Cairns James Cook University Cairns Queensland, Australia